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Pulmonary and systemic hemodynamic responses to ketamine in infants with normal and elevated pulmonary vascular
Insights
Ketamine did not significantly alter pulmonary vascular resistance (PVR) in intubated infants, even those with pre-existing PVR issues. These findings challenge previous recommendations against ketamine use in pediatric patients with pulmonary hypertension.
Area of Science:
- Pediatric Anesthesiology
- Pediatric Critical Care Medicine
- Cardiovascular Physiology
Background:
- Ketamine avoidance is advised for pediatric patients with pulmonary hypertension or limited right ventricular reserve.
- Limited data exists on ketamine's effects on pediatric pulmonary vascular resistance (PVR).
- Adult studies suggest ketamine may increase PVR, but these involved spontaneously breathing patients with unprotected airways.
Purpose of the Study:
- To investigate the hemodynamic effects of ketamine on pulmonary vascular resistance (PVR) in intubated infants.
- To assess ketamine's impact on systemic and pulmonary hemodynamics in infants with and without pre-existing PVR elevation.
Main Methods:
- Hemodynamic parameters were measured in 14 intubated infants receiving minimal ventilatory support (IMV=4, FiO2=0.3-0.4).
- Infants were divided into two groups: normal PVR and pre-existing increased PVR.
- Measurements were taken during spontaneous ventilation, with and without diazepam sedation.
Main Results:
- Ketamine administration did not cause significant changes in cardiac index (CI), PVR index (PVRI), or systemic vascular resistance index (SVRI) in either group.
- No significant differences were observed between infants with normal PVRI and those with pre-existing increased PVRI.
- Results remained consistent in infants receiving diazepam sedation.
Conclusions:
- Ketamine has minimal impact on baseline hemodynamics in mildly sedated, ventilated infants with maintained airways.
- Ketamine administration does not significantly alter PVR in ventilated infants, regardless of baseline PVR status.
- Findings suggest ketamine may be safely used in this pediatric population, contrary to prior recommendations.
Abstract:
Avoidance of ketamine has been recommended in children with pulmonary hypertension or with limited right ventricular reserve, despite absence of data about the effects of ketamine on pulmonary vascular resistance (PVR) in children. Ketamine has been associated with increased PVR in studies of adults; in these studies adults were spontaneously breathing through unprotected airways, despite ketamine's known effects of ventilatory depression and partial loss of airway. The authors measured pulmonary and systemic hemodynamic responses to ketamine during spontaneous ventilation in 14 intubated infants who were receiving minimal ventilatory support with an intermittent mandatory ventilation (IMV) of 4 at an FIO2 of 0.3-0.4. No significant changes were found in cardiac index (CI), pulmonary vascular resistance index (PVRI), or systemic vascular resistance index (SVRI) in a group of seven infants with normal PVRI or in another group of seven infants with preexisting increased PVRI. Results did not differ in infants receiving diazepam sedation. The authors conclude that ketamine has little effect on baseline hemodynamics in mildly sedated infants whose airway and ventilation are maintained; in particular, PVRI is little changed by ketamine administration in ventilated infants with either normal or increased baseline PVRI.